Surgery Exposure Hip - Arthrosurface · Surgery Exposure Hip ... interval between the gluteus maximus and medius; ... a limited extent sufficient to identify specific structures and

Surgery Exposure Hip

1 of 24 11/19/03 1:11 PM

SURGICAL EXPOSURES SURGERY OF THE HIP

Printer friendly pdf file

by R. CALANDRUCCIO

In: Atlas of Orthopaedic SurgeryVolume 3

Lower Extremity; Editors: Laurin, CA, Riley Jr. LH, Roy-Camille R

Reprinted with permission from Masson, copyright Masson, Paris, 1991

Surgical approaches to the hip may be classified as:

— anterior;

— anterolateral;

— lateral;

— posterior;

— medial;

— lateral subtrochanteric and proximal femoral shaft.

The anterior approach utilizes the interval between the sartorius and tensor fascia. The anterolateral approachutilizes the interval between the tensor fascia and the gluteus medius. The lateral approach is essentiallydependent upon elevation of the insertion of the gluteus medius and minimus. The posterior approach utilizes theinterval between the gluteus maximus and medius; in some instances the muscle fibres of the gluteus maximusare separated. The medial approach is between the gracilis and the adductor longus.

Surgical approaches are different from anatomical dissection in so much as the tissue planes are only dissected toa limited extent sufficient to identify specific structures and avoid nerve and vessel damage. There is usually noneed to undermine the skin or dissect the superficial and deep fascia from the underlying structures. Extensionsof the skin incision should not be declined simply to minimize the length of the suture line. “Keyhole” incisions areoften dangerous; skin incisions heal from side to side and not from end to end.

Surgical exposures inevitably produce some degree of tissue damage. The orthopaedic surgeon must be mindfulof the potential consequences of destroying blood supply, especially to bone. However, the advantages obtainedby adequate, open reduction should outweigh the possible complications of the exposure.

If the femoral head is to be retained, the surgeon must be mindful that all surgical exposures of the hip areassociated with the risk of devascularizing the femoral head.

Knowledge of the anatomical structures in the coronal and sagittal planes, as well as the cross-sectionalrelationships, is a prerequisite.

There are many eponyms related to hip joint exposures. With due respect to all who have contributed, no attemptwas made to emphasize author recognition.

ANTERIOR APPROACH

The anterior iliofemoral approach utilizes the interval between the sartorius muscle and the tensor fascia latamuscle.

The entire ilium and hip joint can be reached through the iliac part of the incision. Nearly all hip surgery can becarried out through this approach and separate parts can be used for different purposes. However, it is nowmainly used to expose the anterolateral aspect of the head and neck of the femur and acetabulum for biopsy orexcision of bone in this area. It is difficult to gain direct access to the entire acetabulum, or to deliver theproximal femur out of the wound without extensive stripping of the abductors from the ilium or transecting theexternal rotator tendons.

The lower or distal part of the approach, requires no stripping of muscles, except possibly release of the


2 of 24 11/19/03 1:11 PM

tendinous origin of the rectus femoris. The anatomy of the anterior approach to the hip is illustrated in figures5-1, 5-2, 5-3 and 5-4.

Anterior approach

With the patient supine a pad is placed under the affected hip so that the posterior aspect of the ilium can beexposed, when necessary, and also to facilitate anterior dislocation of the hip. The leg is draped so the hip andleg can be manipulated during the approach.

The skin incision begins at the middle of the iliac crest, 2 centimetres below the crest of the ilium to avoid apainful postoperative scar adherent to bone. The incision is extended anteriorly below the anterior superior iliacspine and curved distally on the lateral aspect of the thigh (Fig. 5-5).

The superficial and deep fascia over the sartorius muscle are divided, medial to the tensor fascia lata muscle. Thelateral femoral cutaneous nerve that penetrates the deep fascia just below the anterior superior iliac spine isidentified and retracted medially along with the sartorius muscle. The interval between the tensor fascia lata andthe sartorius is more easily identified distal to the anterior superior iliac spine (Figs. 5-1 and 5-6); so the dissection should therefore be started distally rather than close to the anterior superior iliac spine.

Part of the anterior aspect of the origin of the tensor fascia is subperiosteally stripped from the ilium. Retractionin this interval exposes the gluteus medius muscle and the rectus femoris muscle, which at this level is easilyidentified because of its fibrous nature, in contrast to the fleshy surrounding muscles.

The ascending branches of the lateral femoral cutaneous circumflex vessels are usually ligated at the lower end ofthe incision (Figs. 5-2 and 5-7).

The tendinous origin of the rectus femoris is separated from the underlying joint capsule, and the direct andreflected origins are released by a transverse cut. The iliopsoas is also separated from the capsule by bluntdissection and retracted medially. Most of the anterior aspect of the hip joint is then exposed (Figs. 5-3, 5-4 and5-8).

The capsule may be incised in line with the axis of the femoral neck and transversely at the edge of theacetabulum, as well as distally (in the form of the letter H). If it is necessary to dislocate the hip anteriorly, asmuch of the capsule is incised or excised as necessary; part of the labrum may also be excised. The femoral headis dislocated by adducting, externally rotating and extending the hip. In young patients, it may be necessary toincise the ligamentum teres before the hip can be completely dislocated. The release of the psoas tendon fromthe lesser trochanter may also be required. The lesser trochanter is exposed by externally rotating the leg,retracting the psoas medially away from the capsule (Figs. 5-4 and 5-8).

To expose more of the ilium or the superior aspect of the acetabulum, the abductor muscle origin is strippedsubperiosteally from the wing of the ilium and retracted posteriorly and laterally (Figs. 5-4 and 5-9). The spacebetween the ilium and this muscle mass is then packed to control bleeding.

Anterior approach

Fig. 5-1. - The line of incision (dotted line) for the anterioriliofemoral approach.

1. Gluteus maximus;

2. Sartorius;

3. Iliopsoas;

4. Lateral femoral cutaneous nerve;

5. Tensor fascia lata;

6. Gluteus medius;

7. Anterior superior iliac spine;

8. Femoral nerve;

9. Rectus femoris.

Fig. 5-2. - Part of the sartorius, tensor fascia latamuscle have been resected to expose the deeperlayer that is encountered when the interval betweenthe tensor fascia lata and sartorius is used.

1-9. See Fig. 5-1; 10. Anterior joint capsule of hip;11. Fascia lata; 12. Ascending branch of lateralfemoral circumflex artery; 13. Profunda femorisarter; 14. Femoral artery and vein.


3 of 24 11/19/03 1:11 PM

Fig. 5-3. - Part of the gluteus medius, minimus andmaximus muscles have been resected to visualizethe underlying anatomy of the anterior approach.

1 to 14. See Fig. 5-1 and 5-2; 15. Greatertrochanter; 16. Piriformis; 17. Reflected head ofrectus femoris; 19. Gluteus minimus; 19. Inguinalligament; 20. Direct head of rectus femoris.

Fig. 5-4. Part of the sartorius, tensor fascia lata, andgluteus muscles have been resected to reveal the deepplane of the anterior retracted medially, part of theanterior capsule has been excised exposing the hip andanterior aspect of the acetabulum. The origin of the rectusfemoris has also been resected.

1 to 20. See Fig. 5-1, 5-2 and 5-3; 21. Joint capsule ofhip; 22. Femoral head.

Fig. 5-5. The skin incision parallels the iliac crest, turnsdownwards below the anterior iliac spine and extendsalong the shaft of the femur (anterior iliofemoralapproach) in the direction of the lateral border of thepatella.

1. Iliac crest; 2. Anterior superior iliac spine.

Fig. 5-6. - The dissection between the tensor fascialata and sartorius is started distally rather than atthe anterior superior iliac spine. The lateral femoralcutaneous nerve is identified and retracted medially.

3. Fascia lata; 4. Fascia over tensor fascia lata; 5.Fascia over sartorius; 6. Lateral femoral cutaneousnerve.

Fig. 5-7. - Retraction of the tensor fascia lata (9) and thesartorius (12) exposes the gluteus medius (11) and rectus femoris (8). The ascending branch of the lateral femoralcircumflex artery (7) has been ligated. The anterior part ofthe tensor fascia lata muscle origin has been stripped fromthe ilium (10).


4 of 24 11/19/03 1:11 PM

Fig. 5-8. - After detaching the rectus femoris (8)from its origin and retracting the iliopsoas (14)medially, much of the anterior aspect of the capsuleis exposed (13).

Fig. 5.9. - After resection of the rectus femoris origin,subperiosteal stripping of the gluteus medius and minimusfrom the ilium exposes the anterior inferior iliac spine andanterior superior iliac spine. With additional subperiostealelevation, the superior aspect of the acetabulum and muchof the iliac wing can be exposed.

1. Femoral head and neck;

3. Anterior inferior iliac spine;

4. Anterior superior iliac spine.

ANTEROLATERAL APPROACHES

The Smith-Petersen anterolateral approach is an extension of the iliofemoral approach to permit exposure of thesubtrochanteric region.

Illustrations of the anatomy of the anterolateral approach (Figs. 5-10, 5-11 and 5-12) are provided for correlationwith the surgical approaches.

Anterolateral approaches

Fig. 5-10. - Skeletal anatomy for anterolateral approach.

1. Femoral head; 2. Anterior inferior iliac spine;3. Anterior superior iliac spine; 4. Posteriorsuperior iliac spine; 5. Vastus ridge; 6. Shaft offemur; 7. Intertrochanteric line; 8. Greatertrochanter.


5 of 24 11/19/03 1:11 PM

Fig. 5.11. - Sartorius, tensor fascia lata muscle, and fascia are partially resected; the gluteusmaximus is reflected posteriorly.

5. Vastus ridge; 10. Vastus lateralis; 11.Superior gluteal artery; 12. Gluteus maximus;13. Gluteus medius; 14. Fascia lata; 15. Tensorfascia lata; 16. Sartorius aponeurosis; 17.Ascending branch of lateral femoral circumflexartery; 18. Iliopsoas; 19. Femoral nerve; 20.Rectus femoris; 21. Sartorius; 25. Capsule; 26.Fascia lata

Fig. 5.12. - Periarticular structuresexposed with partial resection of glutealmuscles and tensor fascia lata muscle.

1. Head of femur; 2. Anterior jointcapsule of the hip; 4. Anterior superioriliac spine; 9. Greater trochanter; 10.Vastus lateralis; 12. Gluteus maximus;13. Gluteus medius; 15. Tensor fascialata; 16. Sartorius aponeurosis; 17.Ascending branch of lateral femoral circumflex artery; 18. Iliopsoas; 20.Rectus femoris; 21. Sartorius; 22.Gluteus minimus; 23. Piriformis; 24.Acetabular rim and labrum; 25.Capsule; 26. Fascia lata.

1° Smith-Petersen anterolateral approach

Smith-Petersen described an anterolateral approach for open reduction and internal fixation under direct vision ofrecent fractures and nonunions of the femoral neck and slipped capital femoral epiphysis. The distal extension ofthe iliofemoral incision exposes the trochanteric region and the upper femur between the vastus lateralis and therectus femoris.

It may be necessary to split muscle fibres to expose the anterior aspect of the femur (Fig. 5-13); however,muscle fibres should not be split too far distally to avoid damage to branches of the femoral nerve as they crossfrom medial to lateral. Posterior retraction of the fascia lata alone provides exposure of the lateral subtrochantericregion. The distal end of the skin incision is curved posteriorly to facilitate exposure of the subtrochanteric region.

Smith-Petersen anterolateral approach

Fig. 5-13. - The Smith-Petersen anterolateral approach is an extensionof the iliofemoral approach.

1. Vastus lateralis; 2. Shaft of femur;3. Periosteum; 4. Rectus femoris; 5.Tendons of gluteus minimus andmedius; 6. Sartorius; 7. Iliopsoas; 8. Femoral neck; 9. Fascia lata; 10.Gluteus minimus and medius; 11.Ilium


6 of 24 11/19/03 1:11 PM

2° Watson-Jones anterolateral approach

The patient is supine and the hip is slightly flexed to relax the anterior structures. The incision is begun a finger’sbreadth distal and lateral to the anterior superior iliac spine and extended distally and posteriorly over the lateralaspect of the greater trochanter and lateral surface of the femoral shaft for approximately 5 centimetres (Fig.5-14).

The interval between the gluteus medius and tensor fascia lata is identified more easily midway between theanterior superior spine and the greater trochanter, rather than at the level of the trochanter. The coarse grain ofthe fibres of the gluteus medius distinguish it from the finer structure of the tensor fascia lata muscle.

Retraction of the anterior edge of the gluteus medius posteriorly and the tensor fascia and rectus anteriorlyexposes the joint capsule (Fig. 5-14 a). The capsule may be incised in a longitudinal or transverse fashion. Theorigin of the vastus lateralis may be reflected distally or split longitudinally to expose the trochanter and proximalaspect of the anterior femoral shaft.

Watson-Jones anterolateral approach

Fig. 5-14. - a) The Watson-Jones approach provides an extension of thelateral subtrochanteric approach foropen reduction of femoral neckfractures.

1. Vastus lateralis; 12. Vastus ridge;13. Gluteus medius; 14. Joint capsule;16. Tensor fascia lata.

b) 1. Vastus lateralis; 14. Capsule; 15.Trochanter

If additional exposure is required, the anterior fibres of the gluteus medius and minimus tendon may be incised orthe anterior superior part of the greater trochanter may be osteotomized with the attached insertion of thegluteus medius muscle (Fig. 5-14 b).

3° Callahan anterolateral approach

The skin incision starts just distal to the anterior superior iliac spine, extends distally to a point approximatelythree finger breadth distal to the lateral prominence of the trochanter and then curves posteriorly, producing ahockey stick shaped incision (Figs. 5-1 and 5-15).

Callahan anterolateral approach


7 of 24 11/19/03 1:11 PM

Fig. 5-15. - The Callahan approach utilizes a hockey stick shaped incision; the intervalbetween the sartorius and tensor fascia lata is used to expose the joint.

1. Incision in vastus lateralis; 2. Gluteus medius; 3. Sartorius; 4. Capsule; 5. Vastus lateralis;6. Tensor fascia lata (sectioned for better visualization).

Insert: Line of incision.

The interval between the tensor fascia and the sartorius space is developed and the tensor fascia lata is dividedtransversely in the distal part of the incision. Proximally, the tensor fascia lata and gluteus muscles are elevatedsubperiosteally and retracted posteriorly. The rectus femoris is retracted medially.

The capsule is then exposed by medial retraction of the iliopsoas and rectus femoris.

When necessary, more exposure can be obtained by subperiosteal stripping of the tensor fascia lata and gluteusmedius muscle from the wing of the ilium (Fig. 5-15).

4° Luck anterolateral approach

In this transverse anterior approach to the hip, the tensor fascia lata is divided transversely while the gluteusmedius and minimus are not disturbed.

The skin incision starts over the femoral head, just lateral to the midpoint between the anterior superior iliacspine and the symphysis pubis, extends laterally parallel to, or in, the flexor crease of the hip and ends justlateral to the greater trochanter (Figs. 5-12 and 5-16 a).

The fascia lata is incised transversely just distal to the trochanter to permit identification of the tensor fascia latamuscle (Fig. 5-11). The muscle is divided at its most distal attachment to the fascia lata. The incised fascia lataand tensor are reflected proximally.

The sartorius and rectus femoris are retracted medially to expose the capsule (Figs. 5-12 and 5-16 b). The originof the rectus femoris may be detached from the pelvis for added exposure of the joint.

Luck anterolateral approach

Fig. 5-16. - a and b) The Luck anterior transverse approach requires sectioning thetensor fascia lata muscle at its distal insertion into the fascia lata.

1. Rectus femoris; 2. Transverse incision; 3. Tensor fascia lata; 4. Anterior superioriliac spine; 5. Sartorius; 6. Iliopsoas

The lateral aspect of the incision may be curved superiorly if the trochanter is to be osteotomized or it may becurved distally if the subtrochanteric and lateral aspects of the femur are to be exposed for internal fixation orosteotomy (Figs. 5-11 and 5-16).

5° Fahey anterolateral approach

This oblique incision extends from the anterior superior iliac spine to a point distal to the prominence of the


8 of 24 11/19/03 1:11 PM

greater trochanter and ends at the midpoint of the lateral aspect of the thigh (Fig. 5-17 insert).

Fig. 5-17. - The Fahey approach facilitates arthrotomy of the hip as well as exposure of thelateral subtrochanteric area.

1. Fascia lata; 2. Tensor fascia lata; 3. Head offemur; 4. Gluteus minimus; 5. Straight head ofrectus femoris muscle cut; 6. Psoas muscle; 7.Vastus lateralis; 8. Femoral shaft; 9. Gluteusmaximus insertion.

The skin and superficial fascial are retracted and the plane between the tensor fascia lata and the sartorius isdeveloped. The iliotibial band is divided transversely at the distal insertion of the tensor fascia lata muscle intothe iliotibial band. The straight head of the rectus is divided and the psoas tendon is separated from the anteriorcapsule and retracted medially. The joint capsule is now opened longitudinally and cut transversely near the rimof the acetabulum.

The vastus lateralis muscle is separated from the femur and retracted anteriorly to expose the subtrochantericand lateral aspects of the proximal femur (Fig. 5-17).

6° Charnley anterolateral approach

With the patient supine, the hip is placed near the edge of the table so that the skin and adipose tissues of thebuttock will hang over the side. A sandbag under the buttock will elevate the trochanter and make draping easier.The sandbag may have to be removed when the implants are inserted in order to assess their position moreaccurately. For this reason, some prefer an air bag that can be deflated or they temporarily tilt the table. The legis draped so that it can be manipulated during the procedure. The hip is flexed 30 degrees and adducted slightlyto make the trochanter more prominent and to move the tensor fascia lata anteriorly.

The incision starts several centimetres distal to the iliac crest, extends to the tip of the trochanter, crosses theposterior aspect of the trochanter and runs down the shaft of the femur. The incision may also start moreanteriorly, at the level of, and approximately 5 centimetres behind, the anterior superior spine (Fig. 5-18).

Charnley anterolateral approach

Fig. 5-18. - A straight (Fig. 5-19) or a cursed (Fig. 5-18) incision may be used for theanterolateral approach.

1. Anterior superior iliac spine; 2. Sartorius;3. Tensor fascia lata; 4. Rectus femoris; 5.Vastus lateralis; 6. Iliotibial band; 7. Bicepsfemoris; 8. Gluteus maximus; 9. Gluteusmedius; 10. Iliac crest.

Fig. 5-19. - The tensor fascia is incised in line with the skin incision and behind thetensor fascia lata muscle.

3. Fascia over tensor fascia lata; 5. Vastuslateralis; 6. Iliotibial band.


9 of 24 11/19/03 1:11 PM

Fig. 5-20. - The fat tissue is removed with blunt dissection revealing the underlying jointcapsule and medially the tendon of the rectusfemoris muscle. External rotation of legmakes capsule more taut.

5. Vastus lateralis; 11. Tendon of rectusfemoris; 12. Psoas; 13. Greater trochanter.

The subcutaneous adipose tissue is incised in line with the skin incision down to the deep fascia. The fascia isincised starting over the greater trochanter and then distally for approximately 5 centimetres, exposing theunderlying vastus lateralis. The fascial incision is extended proximally behind the posterior border of the tensorfascia lata muscle (Fig. 5-19). If the fascial incision is too posterior, the gluteus maximus fibres will beencountered; if it is too anterior, the tensor fascia lata muscle fibres will be sectioned.

Some authors prefer to go through the fascia covering the tensor muscle and detach this muscle inferiorly fromthe fascia lata (Roy-Camille).

Retraction of fascia lata muscle anteriorly and the gluteus maximus posteriorly, exposes the underlying gluteusmedius and greater trochanter. Any fibres of the gluteus medius arising from the undersurface of the fascia lataare detached by blunt dissection.

The interval between the anterior edge of the gluteus medius and the tensor fascia lata is identified; the gluteusmedius and minimus are retracted laterally and posteriorly, while the tensor is retracted medially therebyexposing the fatty tissue overlying the joint capsule. The origin of the vastus lateralis is detached from the frontof the greater trochanter. The hip is now externally rotated and slightly flexed to reduce the tension on theabductor muscles and make the anterior part of the capsule taut (Fig. 5-20).

If the procedure is to be done without osteotomizing the greater trochanter, an incision is made in the anteriorinsertion of the gluteus medius and minimus detaching them from the greater trochanter, but leaving a cuff oftendon for re-attachment (Fig. 5-21). The incision is then vertical and proximal, in the substance of the gluteusmedius (Fig. 5-21, insert).

The capsule is cut and the head and neck are exposed (Fig. 5-22). With the leg adducted, the capsule issufficiently resected so that with external rotation, the hip is dislocated anteriorly. Additional capsule is cut asnecessary to retract the head and neck posteriorly for visualization of the acetabulum.


Fig. 5-21. - If the trochanter is notosteotomized, an incision is made in the anterior insertion of the gluteus mediusdetaching it from the trochanter but leavinga cuff of tendon for re-attachment. Theincision in the gluteus medius is extendedproximally from the tip of the trochanter(see insert).

3. Tensor fascia lata; 5. Vastus lateralis; 9.Gluteus medius; 11. Rectus femoris; 13. Greater trochanter; 14. Joint capsule.

Fig. 5-22. - With the leg adducted the capsule isresected and then with flexion and externalrotation the hip is dislocated anteriorly.

3. Tensor fascia lata; 8. Gluteus maximus; 9.Gluteus medius; 13. Greater trochanter; 15. Neckof femur; 16. Head of femur.


10 of 24 11/19/03 1:11 PM

Fig. 5-23. - A long heavy clamp is insertedeither intracapsular as above, orextracapsular, to act as a guide for theosteotomy of the greater trochanter using aGigli saw, an osteotome or an oscillatingsaw.

Fig. 5-24. - An osteotomy of the greatertrochanter should exit on the trochanter just abovethe prominence of the abductor tubercle.

If the joint is exposed by osteotomizing the trochanter, an instrument is inserted as illustrated in figure 5-23under and medial to the gluteus medius and minimus, either intracapsular or extracapsular, to serve as a guidefor osteotomy of the greater trochanter. The vastus lateralis origin from the trochanter stripped and retracteddistally. A wide osteotome, a Gigli saw or a reciprocating saw are used to osteotomize the greater trochanter asillustrated in figures 5-23 and 5-24. Care is taken not to damage the sciatic nerve posterior to the greatertrochanter. Part of the abductor tubercle should be left attached to the shaft (Fig. 5-24).

The osteotomized greater trochanter is retracted superiorly and then, with slight flexion of the hip, it is possibleto detach the origin of the rectus from the front of the hip joint (Fig. 5-25). The capsule is now incised in line withthe neck of the femur and transversely at the acetabulum. With external rotation, the hip can usually bedislocated anteriorly, though it may be necessary to incise the attachment of the gluteus maximus to theposterior aspect of the femur (Fig. 5-26 b). It may also be necessary to incise the capsule inferiorly and to detachthe psoas tendon from the lesser trochanter.

The neck of the femur is then osteotomized, either by using a Gigli saw or reciprocating saw. An osteotomeshould not be used for fear of fracturing the inferior cortex of the neck (Fig. 5-27).

After the head has been removed, a flat retractor can be inserted behind the lip of the acetabulum to lever theinternally rotated femur posteriorly, thus providing direct access to the acetabulum (Fig. 5-28).

Self-retaining retractors are utilized to retract the osteotomized greater trochanter and the cut surface of thefemur as well as the fascia lata and gluteus maximus (Fig. 5-29).

If at any time during the procedure exposure of the shaft is necessary, the skin incision is extended along theshaft of the femur and the vastus lateralis is either split, as illustrated in figure 5-30, or retracted.


Fig. 5-25. - The hip is flexed and the rectusfemoris origin is detached from the edge ofthe acetabulum.

3. Tensor fascia lata; 4. Reflected head ofrectus femoris; 9. Gluteus medius; 13.Osteotomized greater trochanter.


11 of 24 11/19/03 1:11 PM

Fig. 5-26. - The capsule is incised as illustrated and with external rotation and adductionthe hip is dislocated. If necessary, the fibres of the gluteus maximus attached to the femurare incised (insert).

5. Vastus lateralis; 8. Gluteus maximus tendon; 14. Joint capsule; 15. Femoral head andneck; 17. Line of proximal fasciotomy; 18. Superior rim and labrum of acetabulum; 19.Femoral shaft.

Fig. 5-27. - The femoral head can bedivided with a Gigli saw or, better still, withan end-cutting reciprocating saw.

Fig. 5-28. - After osteotomy of the femoralneck, the femur is retracted posteriorly by aretractor inserted behind the posterior edgeof the acetabulum.

3. Tensor fascia lata; 5. Vastus lateralis; 6.Fascia lata; 9. Gluteus medius; 13. Greatertrochanter; 14. Joint capsule; 15. Neck of femur; 20. Acetabulum.

Fig. 5-29. - Self retaining retractors are inserted between the gluteus maximusposteriorly and the tensor fascia lataanteriorly; a second self-retaining retractorbetween the greater trochanter andosteotomized surface of the femur provides excellent exposure of the acetabulum. A Hohmann's retractor inserted over theanterior quadrant of the acetabulum is alsohelpful.


12 of 24 11/19/03 1:11 PM

Fig. 5-30. - If necessary, at any time in theprocedure, the vastus lateralis can bedivided or the whole muscle retracted anteriorly to expose the shaft of the femur.

4. Reflected head of rectus femoris; 5.Vastus lateralis; 6. Fascia lata; 9. Gluteusmedius; 13. Proximal femur (greatertrochanter osteotomized); 14. Joint capsule;15. Femoral head and neck; 19. Shaft offemur; 21. Capsule and roof of acetabulum.

LATERAL APPROACHES

1° Ollier lateral approach

The U-shaped incision starts near the anterior superior iliac spine, continues downwards and distal to thetrochanter, curves across the lower aspect of the trochanter, extends posterior superiorly, ending midwaybetween the trochanter and posterior superior iliac spine. The gluteal fascia is incised in line with the skin incision(Fig. 5-31 a).

The interval between the tensor fascia and the gluteus medius is identified midway between the anterior superioriliac spine and the trochanter. The anterior border of the gluteus medius is dissected down to the trochanter.Posteriorly, the interval between the anterior border of the gluteus maximus and the posterior border of thegluteus medius muscle is identified. The anterior edge of the gluteus maximus is reflected posteriorly byextending the fascial incision distally.

The trochanter is now osteotomized obliquely at its base, taking care to preserve the insertion of the gluteusmedius and minimus, as well as the piriformis, obturator and gemelli muscles. The trochanter with its tendinousinsertions is then reflected upwards and backwards to expose the joint (Fig. 5-31 b).

Additional exposure may be obtained by adding a distal extension from the base of the trochanter parallel to thefemur for a distance of approximately 10 centimetres, transforming the original U-shaped skin incision into a Yconfiguration.

Ollier lateral approach

Fig. 5-31. - a and b) Ollier lateral approach.1. Gluteus medius; 2. Gluteus maximus; 3. Detached greater trochanter; 4. Superior rim of

acetabulum; 5. Capsule of hip joint.

2° Hardinge lateral approach

The patient is in the lateral position to facilitate a direct lateral approach following an anterior dislocation of thehip.

The bulk of the gluteus medius is preserved intact and the trochanter is not osteotomized. It does not provide aswide an exposure as the anterolateral approaches with osteotomy of the trochanter or the posterior approaches.

The tensor fascia lata is retracted anteriorly and the gluteus maximus posteriorly (Fig. 5-32 a). The incisionfollows the superior and anterior borders of the greater trochanter, incising the attachment of the gluteus mediusbut with a cuff of tendon still attached to the greater trochanter (Fig. 5-32 b).


13 of 24 11/19/03 1:11 PM

The incision starts at the apex of the trochanter and extends proximally in line with the fibres of the gluteusmedius. Distally, the incision extends into the anterior surface of the femur, detaching part of the vastus lateralis.The part of the gluteus medius that is detached from the trochanter is essentially the internal rotator segment;that which is left attached is the main part of the abductor mass of the gluteus medius.

The leg is adducted and the portion of the vastus lateralis that arises from the intertrochanteric line, the insertionof the gluteus medius and ligament of Bigelow are detached and retracted. Further detachment and elevation ofthese muscles and ligaments allow anterior dislocation of the hip following adduction and external rotation of theleg (Fig. 5-32 c). At the time of closure, the incision in the gluteus medius and vastus lateralis is closed (asillustrated in figure 5-32 d).

Hardinge lateral approach

Fig. 5-32. - a, b, c and d) Hardinge direct lateral approach with anterior dislocation of the hip.1. Abductor portion of gluteus medius; 2. Internal rotator protion of gluteus medius.

3° McFarland and Osborne

lateral approach

The McFarland and Osborn approach is similar to the Hardinge approach except that the hip is dislocatedposteriorly with the patient in the lateral position. It is based on the observation that the gluteus medius and thevastus lateralis are in direct functional continuity through the thick tendon and periosteum covering the greatertrochanter. The integrity of the gluteus medius muscle is protected during the posterior dislocation of the hip. Thetwo muscles meet at a right angle anteriorly, so with detachment of the periosteum and tendon it is possible todisplace the two muscles forward like a bucket handle (Fig. 5-33 b). If the periosteum is difficult to strip, a smallamount of bone is osteotomized with the tendinous attachment to allow anterior retraction.

McFarland and Osborne lateral approach


14 of 24 11/19/03 1:11 PM

Fig. 5-33. - McFarland and Osborne approach with detachment of gluteus medius andvastus lateralis in continuity. Posterior dislocation after detaching gluteus minimus.1. Vastus lateralis; 2. Tensor fascia lata; 3. Gluteus medius; . Gluteus maximus; 5.Gluteus minimus; 6. Greater trochanter.

The posterior border of the gluteus medius is clearly defined and separated from the piriformis by blunt dissection(Fig. 5-33 a). The gluteus minimus is divided so that it can be retracted upwards to expose the capsule of thejoint (Figs. 5-33 c and d). The hip is dislocated posteriorly by internal rotation and adduction of the hip.

At closure, the gluteus minimus and capsule are reattached as one. The gluteus medius and vastus lateralis arereturned to their original position and sutured to the undisturbed portion of the vastus lateralis while the insertionof the gluteus maximus to the femur is repaired if it has been sectioned.

4° Jergesen and Abbott lateral approach

An oblique incision is made from the anterior superior iliac spine to 5 centimetres below the gluteal fold with thepatient in the direct lateral position (Fig. 5-34 a).

The interval between the tensor and the gluteus medius is developed and the fascia is incised distally in line withthe posterior aspect of the femoral shaft (Fig. 5-34 b). Anteriorly the dissection extends between the tensor andgluteus medius to the capsule (Fig. 5-34 c). The origin of the rectus is retracted medially.

Curved instruments are placed between the capsule and the gluteus minimus and medius muscles so that thetrochanter can be osteotomized extracapsularly (Fig. 5-34 d). The anterior and anterolateral capsule is thenincised; the attachment of the psoas tendon to the lesser trochanter may be transected. The hip is thendislocated anteriorly.

Jergensen and Abbott lateral approach


15 of 24 11/19/03 1:11 PM

Fig. 5-34. - a, b and c) The Jergesen and Abbott approach permits extensive exposureof the hip and allows anterior and posterior dislocation after osteotomizing the greater

trochanter.1. Tensor fascia lata; 2. Iliotibial tract; 3. Fascia lata; 4. Gluteus minimus; 5. Lateral

femoral circumflex vessels; 6. Psoas; 7. Rectus femoris; 8. Gemelli and obturatorexternus; 9. Piriformis; 10. Gluteus medius.

If further exposure is required, or if the hip is to be dislocated posteriorly, the tendinous attachment of thegluteus maximus to the femoral shaft is incised near the trochanter. The external rotator muscles are alsodetached from the back of the femur. The osteotomized trochanter is retracted superiorly and the capsule cannow be incised or excised both anteriorly and posteriorly. The entire circumference of the acetabulum is nowexposed.

5° Harris lateral approach

This approach permits both anterior and posterior dislocations of the hip. The patient is in the lateral position.

The skin incision is U-shaped with the bottom of the U at the posterior border of the greater trochanter. It starts5 centimetres posterior and slightly proximal to the anterior superior iliac spine, curves distally and posteriorly tothe posterior superior corner of the greater trochanter and then longitudinally for approximately 8 centimetres,curving gradually anteriorly and distally so that both limbs of the U are almost symmetrical (Fig. 5-35). Theiliotibial band is incised to the distal aspect of the skin incision.

The femoral insertion of the gluteus maximus on the gluteal tuberosity is identified and the incision in the fascialata is extended approximately one finger’s breadth anterior to that insertion. The incision in the iliotibial band iscarried proximally along the skin incision releasing the fascia over the gluteus medius.

The exposure to the posterior aspect of the joint capsule is limited by the posterior aspect of the fascia lata andthe gluteus maximus fibres that insert into it. For wider posterior exposure, for posterior dislocation of the head,a short oblique incision can be made into the deep surface of the posteriorly reflected fascia lata and into part ofthe substance of the gluteus maximus. This transverse incision is at the level of the greater trochanter (Fig.5-35).

Harris lateral approach

Fig. 5-35. - Harris lateral approach. A relaxing incision is made in the posteriorpart of the fascia lata and extended into partof the gluteus maximus to expose the short external rotators and the posterior portion ofthe capsule.1. Vastus lateralis; 2. Greater trochanter; 3.Gluteus maximus; 4. Gluteus medius.

Fig. 5-36. - The line of the osteotomy of the trochanter isdefined. The osteotomy may be performed with a wideosteotome or reciprocating saw.


16 of 24 11/19/03 1:11 PM

Fig. 5-37. - The osteotomized greatertrochanter is reflected and the short externalrotator muscles are detached from their insertion into the greater trochanter. The posterior capsule can then be visualized andis detached from the posterior rim of theacetabulum (not illustrated).2. Osteotomized greater trochanter; 4.Gluteus medius; 7. Iliopsoas; 8. Obturatorexternus (cut); 9. Obturator internus; 10.Piriformis; 11. Gluteus minimus.

Fig. 5-38. - The hip is dislocated anteriorly by externalrotation, adduction and the osteotomized greater trochanteris placed in the acetabulum (2).

Fig. 5-39. - The entire circumference of theacetabulum is exposed by retracting thegreater trochanter superiorly and dislocatingthe femoral head posteriorly by internal rotation. 7. Iliopsoas; 12. Acetabulum.

To develop the anterior exposure of the joint, the iliotibial band and fascia lata muscle are reflected anteriorly.Before osteotomizing the greater trochanter and the attached abductor muscles, the origin of the vastus lateralisis reflected distally, exposing the abductor tubercle at the inferior level of the trochanter.

An instrument is now passed transversely between the capsule and the abductor muscles (Fig. 5-36). The greatertrochanter is osteotomized with either a wide osteotome or a reciprocating saw, starting below the abductortubercle and in line with the femoral neck. The piriformis, obturator externus and internus are incised where theyattach to the trochanter (Fig. 5-37). The anterior and posterior aspects of the capsule are now incised or excisedexposing the neck and head, as well as the lateral aspect of the acetabulum. Special care must be taken to avoiddamage to the sciatic nerve posteriorly.

To expose the joint anteriorly, a blunt instrument such as a Bennett retractor is placed deep to the rectus femorison the anterior inferior iliac spine, and soft tissues are thus retracted medially. By reflecting the greatertrochanter superiorly, the acetabulum is exposed. A thin retractor can be placed between the capsule andiliopsoas to expose the anterior and inferior aspects of the capsule. As much of the capsule as desired is excisedanteriorly and posteriorly.

The femoral head can now be dislocated posteriorly. To expose the full circumference of the head, theosteotomized part of the trochanter with the attached muscle pedicle is placed in the acetabulum and the femur isexternally rotated (Fig. 5-38). To expose the entire acetabulum, the greater trochanter is retracted superiorly andthe femoral head is dislocated posteriorly by adducting, flexing and internally rotating the hip (Fig. 5-39). Flexionof the knee reduces tension on the sciatic nerve while the head is dislocated posteriorly.

At the time of closure, the hip is placed in approximately 20 degrees of abduction and slight external rotation.The trochanter is fixed to the side of the femoral shaft with several wire loops or two screws.


17 of 24 11/19/03 1:11 PM

It is rarely necessary to dislocate the hip both anteriorly and posteriorly to visualize both the anterior andposterior parts of the capsule. However, if the patient has a flexion contracture, the anterior exposure allowsrelease of the capsule, as well as of the rectus and psoas. The arthroplasty may be performed following eitheranterior or posterior dislocation.

POSTERIOR APPROACH

A number of approaches are classified as posterior. They vary from the extensive Henry approach that releasesthe gluteus maximus from the iliac crest, the iliotibial band and the femoral shaft to essentially expose all of theposterior structures (Figs. 5-41 and 5-42) to the limited muscle splitting approach of Ober for drainage of the hipjoint.

They all have in common the posterior retraction of the gluteus maximus to enter the posterior aspect of the hipand the release of the short external rotator muscles to enter the hip joint.

They vary mainly as to whether the deep posterior compartment is entered by incising the iliotibial band and thegluteus maximus muscle in line with the axis of the shaft, or separating the muscle fibres of the gluteus maximusproximally. They also vary depending on whether the abductors are released from the trochanter and, if released,whether the tendinous attachment is transected or the trochanter is osteotomized.

Posterior approach

Fig. 5-40. - Skeletal anatomy in reference toposterior approach.

Fig. 5-41. - The gluteus maximus andmedius have been partially resected to demonstrate the structures that areexposed following retraction of thesemuscles.1. Gluteus maximus; 2. Gluteus medius; 3.Superior gluteal artery; 4. Gluteusminimus; 5. Greater trochanter; 6.Obturator externus; 7. Sciatic nerve; 8.Quadratus femoris; 9. Vastus lateralis; 10.Medial femoral circumflex artery; 11.Adductor magnus; 12. Common tendon of hamstrings (origin); 13. Ischial tuberosity;14. Inferior gemellus; 15. Obturatorinternus; 16. Superior gemellus; 17.Inferior gluteal nerve and artery; 18.Piriformis; 19. Superior gluteal nerve.

Fig. 5-42. - The short external rotator muscles,the sciatic nerve, the gluteus maximus andmedius have been transected.1. Gluteus maximus; 2. Gluteus medius; 3.Superior gluteal nerve and artery; 4. Gluteusminimus; 5. Greater trochanter; 6. Tendon ofobturator externus (insertion); 7. Sciatic nerve; 8.Quadratus femoris; 9. Vastus lateralis; 10. Medialfemoral circumflex artery; 11. Adductor magnus;12. Common tendon of hamstrings (origin); 13.Sacrotuberous ligament; 14. Inferior gemellus;15. Tendon of obturator internus (insertion); 15.Obturator internus; 16. Superior gemellus; 17.Inferior gluteal artery; 18. Tendon of piriformis(insertion); 18. Piriformis; 19. Superior glutealnerve and artery; 20. Lateral joint capsule of hip;21. Tendon of iliopsoas (insertion into lessertrochanter); 22. Head of femur

Almost all of the approaches have the option to release the abductors, depending on the need for addedexposure.

The posterior approach that Moore popularized, and which is often referred to as the "Southern approach", is avariation of the original Henry approach and of the modifications subsequently made by Kocher, Osborne and


18 of 24 11/19/03 1:11 PM

Gibson. The Moore approach will be discussed here because it is the most commonly used approach forendoprostheses, total hip arthroplasty, open reduction of hip dislocation, removal of loose fragments in the joint,repair of acetabular fractures, drainage of the hip and vascular muscle pedicle graft procedures.

Three anatomical illustrations are included in this section for reference (Figs. 5-40, 5-41 and 5-42).

Moore posterior approach

The patient is securely fixed in the lateral position with the involved side uppermost. The leg is draped so that itcan be manipulated during the procedure. It is well to drape in such a manner that the anterior superior spine canbe palpated as a reference point.

The incision starts 10 centimetres from the posterior superior iliac spine, is directed laterally and distally to theback of the trochanter and extends for 10 or more centimetres, parallel to the shaft of the femur (Fig.5-43).

The deep fascia is exposed and the iliotibial band is incised from the trochanter to the distal end of the incision(Fig. 5-44). The fascial incision is now carried into the gluteus maximus muscles separating the oblique, coarsefibres in the direction of the skin incision.

Retraction of the gluteus maximus muscle reveals (Fig. 5-45) the back of the trochanter and the adipose tissueoverlying the short external rotator muscles. Special care is taken to place the inferior retractor in the gluteusmaximus muscle and not place the tip injudiciously for fear of injury to the sciatic nerve. In most instances, thesciatic nerve does not have to be identified and protected; however, in patients with protrusio acetabuli or incongenital dislocation of the hip, the nerve may be near the back edge of the acetabulum and it is wise to identifyit and to protect it.

Moore posterior approach

Fig. 5-43. - Moore posterior approach.

Fig. 5-44. - The incision is made in the fascia lataat and below the greater trochanter beforeextending the incision proximally into the fibres ofthe gluteus maximus.

Fig. 5-45. - Retraction of the gluteusmedius and gluteus maximus exposes theshort external rotator muscles. 1. Gluteus medius; 2. Vastus lateralis; 3.Quadratus femoris; 4. Fascia lata; 5. Gluteusmaximus.

Blunt dissection will usually remove the adipose tissue from the short external rotators; internal rotation of thehip makes them more prominent and displaces their insertion away from the sciatic nerve (Fig. 5-46). The external rotator muscles are transected near their attachment to the trochanter. Prior to sectioning of thetendons, they may be tagged with a nonabsorbable suture so that they may be re-attached at the end of theprocedure.

The capsule may or may not be sectioned along with the short external rotators (Fig. 5-47). The capsule is nowopened in line with the axis of the neck and a transverse incision is made at the edge of the acetabulum.


19 of 24 11/19/03 1:11 PM

Fig. 5-46. - Internal rotation and detachmentof the short external rotator muscles along theback of the trochanter (dotted line).1. Sciatic nerve.

Fig. 5-47. - The short external rotators havebeen sectioned and reflected posteriorly toprotect the sciatic nerve. The quadratus femorishas been released from the trochanter; theiliopsoas tendon is now seen and may besectioned to allow dislocation of the hip. Alsothe gluteus maximus tendon attached to thefemur has been released prior to dislocation.1. Gluteus medius; 2. Vastus lateralis; 3.Quadratus femoris (cut); 4. Fascia lata; 5.Gluteus maximus; 6. Iliopsoas tendon.

Fig. 5-48. - The head is dislocated byadduction, internal rotation and flexion of thehip with the foot above. The transverse axis ofthe knee joint is parallel to the floor whichprovides a point of reference for anteversion ofthe neck of the femur.

Fig. 5-49. - Ludloff medial approach. Skeletal anatomy of the medial approach of the hip.1. Lesser trochanter; 2. Anterior superior iliacspine; 3. Inguinal ligament.

The hip is now gently adducted, internally rotated and flexed. Dislocation should not be forceful especially if thereis any degree of osteopenia or weakening of the shaft for any reason. More capsule may have to be incised,especially inferiorly and medially; it may also be necessary to incise the quadratus femoris muscle to dislocate thehip. In addition, it is at times necessary to detach the psoas tendon from the lesser trochanter. The lesser


20 of 24 11/19/03 1:11 PM

trochanter can be identified after release of the quadratus. Removal of part of the labrum and posteriorosteophytes on the acetabulum, in order to dislocate the hip with ease, is sometimes necessary. Sectioning theneck with an end-cutting reciprocating saw may be necessary if the hip is fused, if there are intra-articularadhesions, or if the head is grossly distorted and cannot be easily dislocated.

The hip may now be dislocated as illustrated in figure 5-48. This places the axis of the knee joint parallel to thefloor so that the anteversion of the neck and the position of the femoral prosthesis can be properly evaluated.

In procedures in which the femoral head is not sacrificed, such as drainage of the hip, reduction of a posteriordislocation, removal of fragments from the joint, repair of acetabular fractures, or resurfacing procedures, specialcare must be taken to avoid injury to the medial circumflex and retinacular vessels. The short external rotatormuscles are sectioned close to the edge of the acetabulum, rather than at the insertion in the trochanter, and thecapsular incisions are made near the acetabular edge rather than near the attachment of the capsule to the neck.The medial circumflex vessels are at risk during the dissection near the attachment of the psoas tendon to thelesser trochanter (Fig. 5-49).

MEDIAL APPROACH

Ludloff described a medial approach for open reduction of congenital dislocation of the hip, but it is now mostused for obturator neurectomy, psoas tendon release and selective adductor tenotomy. To a lesser extent, it isused for biopsy and removal of tumors near the lesser trochanter, the medial aspect of the neck and the proximalshaft of the femur. It is difficult to extend the incision proximally. Furthermore, the medial circumflex vessel, themain blood supply to the femoral head, may be jeopardized.

For this reason, and because of a lack of familiarity with this exposure, most surgeons prefer to expose the lessertrochanter through a Hueter-Schede approach (lower limit of the Smith-Petersen iliofemoral incision) or throughthe posterior approach.

Ludloff medial approach.

With the patient supine and a pad under the buttock, the affected hip is flexed, abducted and externally rotated(Fig. 5-49). Very careful preparation and draping of the operative field is necessary because of the proximity ofthe perineum.

A longitudinal incision is made over the adductor longus; with the leg in the above position it is the mostprominent of the adductor muscles (Fig. 5-50). The incision begins approximately 3 centimetres below the pubictubercle and extends distally for at least 8 centimetres.

The gracilis muscle lies posterior to the adductor longus. These two muscles are innervated by the anterior branchof the obturator nerve at the proximal end of the incision (Fig. 5-51). Separation of the two muscles (Fig. 5-52)and retraction of the adductor longus superiorly and the gracilis inferiorly exposes the underlying adductor brevismuscle (Fig. 5-53); the adductor magnus is posterior to the brevis. The anterior branch of the obturator nerveoverlies the adductor brevis (Figs. 5-51 and 5-53). Retraction of the adductor longus and brevis superiorlyexposes the posterior branch of the obturator nerve overlying the adductor magnus (Figs. 5-51 and 5-54). It isthe adductor brevis, therefore, that separates the anterior and posterior branches of the obturator nerve (Fig.5-51). The adductor brevis is innervated by the anterior branch and the adductor magnus is innervated by thesciatic nerve.

Retraction of the adductor brevis anteriorly and the adductor magnus inferiorly exposes the lesser trochanter, themedial aspect of the neck and the proximal aspect of the femur (Fig. 5-54). Careful blunt dissection is advised.The medial femoral circumflex artery passes around the medial side of the psoas tendon and is, therefore, subjectto damage, especially in children (see Fig. 5-42).

Ludloff medial approach

Fig. 5-50. - Ludloff medial approach.Superficial anatomy of the medial approach.The incision and dissection are made betweenthe adductor longus and gracilis muscles asindicated by the dotted line.4. Sartorius; 5. Iliacus; 6. Psoas muscle; 7.Femoral nerve; 8. Femoral artery; 9. Iliac vein;10. Pectineus; 11. Gracilis; 12. Adductorlongus; 13. Profunda femoris artery; 14.Adductor magnus.

Fig. 5-51. - Part of the sartorius, gracilis andadductor longus muscles have been resected touncover the deeper anatomy. The relationshipof the obturator nerve branches to the adductorbrevis muscles and the proximity of medialcircumflex vessels should be noted.


21 of 24 11/19/03 1:11 PM

1. Lesser trochanter; 4. Sartorius; 8. Femoralartery; 10. Pectineus; 11. Garcilis; 12. Adductorlongus; 13. Profunda femoris artery; 14.Adductor magnus; 15. Vastus medialis; 16.Inferior joint capsule of hip; 17. Medial femoralcircumflex artery; 18. Obturator nerve; 19.Adductor brevis.

Fig. 5-52. - After incising the fascia in linewith the skin incision, the interval between thegracilis (11) and adductor longus (12) is identified.

Fig. 5-53. - Retraction of the adductor longuswhich uncovers the adductors brevis and theoverylying of the anterior branch of theobturator nerve.12. Adductor longus; 14. Adductor magnus; 18.Obturator nerve; 19. Adductor brevis; 20.Anterior branch of obturator nerve.

Fig. 5-54. - Retraction of the adductor brevismuscle superiorly and laterally demonstratesthe posterior branches of the abturator nervethat is on the surface of the adductor magnus.The lesser trochanter can be palpated alongthe lateral edge of the adductor magnus.<1. Lesser trochanter; 11. Gracilis; 12.Adductor longus; 14. Adductor magnus; 19. Adductor brevis; 21. Posterior branches ofobturator nerve.

The anterior branch of the obturator nerve innervates the adductor brevis as well as the gracilis. This anteriorbranch also supplies a cutaneous nerve that extends to the medial aspect of the knee, accounting for pain in thisregion in many patients with hip joint pathology, especially slipped femoral epiphysis. The posterior branchsupplies the obturator externus in the pelvis and at the level of this incision it supplies the adductor magnus.

If a selective adductor tenotomy is to be performed with an obturator neurectomy, a transverse rather than alongitudinal incision may be used. This provides better exposure of the origin of the adductors so they can besectioned close to their origin from the pelvis. To correct an adductor deformity, the adductor longus is sectionedat its pelvic origin and turned downwards and laterally. There may be some bleeding from the branches of theexternal pudendal artery and vein. The origins of the adductors brevis and gracilis are also sectioned close to thepelvis. The adductor magnus may be stripped from the lateral surface of the inferior ramus of the pelvis andischium.

LATERAL APPROACH

TO THE SUBTROCHANTERIC REGION

AND LATERAL ASPECT

OF THE PROXIMAL FEMORAL SHAFT

This approach is utilized for internal fixation of femoral neck, as well as for open reduction and fixation ofintertrochanteric fractures and core decompression procedures of the femoral neck and head.


22 of 24 11/19/03 1:11 PM

With the patient in a supine position, on a fracture or a standard operating table, a linear incision is made overthe posterolateral aspect of the trochanter and extended distally on the lateral aspect of the thigh, parallel to theshaft, 10 centimetres or more. The underlying fascia lata is divided in line with the skin incision and is splitposterior to the tensor fascia lata muscle.

Retraction then exposes the fascia of the underlying vastus lateralis muscle (Fig. 5-55). With retraction, thelateral aspect of the shaft is exposed. The proximal tendinous origin of the muscle may be divided transverselyand elevated to expose the lateral aspect of the femur distal to the abductor tubercle (Fig. 5-56).

The muscle is now divided along the posterior lateral border of the femoral shaft. If the muscle is separated fromthe shaft close to the linea aspera, the perforating vessels that are divided will be difficult to cauterize becausethey will retract into the posterior aspect of the thigh. To avoid this, it is advisable to longitudinally split themuscle I or 2 centimetres from the linea aspera and thereby more easily identify and cauterize these vessels (Fig.5-57).

The body of the vastus lateralis is retracted superiorly and the lateral aspect of the femur is exposed by bluntdissection with a periosteal elevator. Proximally, subperiosteal elevation of the vastus lateralis and intermediuswill expose the intertrochanteric line (Fig. 5-57). The soft tissue attachment to the posterior inferior aspect of thefemur may have to be released for open reduction of an intertrochanteric or subtrochanteric fracture.

Since the skin and vastus lateralis muscle have been incised posterolaterally, the bone is exposed bysuperomedial retraction; little or no inferior retraction is usually necessary (Figs. 5-55 and 5-56).

Lateral approach of the subtrochanteric region

Fig. 5-55. - Lateral approach to the subtrochanteric region and lateral aspect of the proximalfemoral shaft.

a) The skin and fascial incision are made posterolateral so that the tensor fascia lata muscle(1) will be retracted superiorly and medially along with the fascia (2).

b) The detachment of the vastus lateralis (3) from the shaft exposes the gluteus maximusinsertion (4) and provides excellent exposure of the shaft.

The exposure may be extended distally to the supracondylar area of the femur if necessary. To expose thefemoral neck and head anteriorly, the skin incision is extended superomedially and the dissection is carriedproximally in the interval between the tensor fascia lata muscle and the gluteus medius (Watson-Jones approach,see Fig. 5-14). Transverse section of the tensor fascia lata muscle at its attachment to the fascia lata and flexionof the hip joint will facilitate additional exposure of the anterior aspect of the joint capsule. If still furtherexposure is necessary for open reduction of a femoral neck fracture or slipped capital femoral epiphysis, thegreater trochanter may be osteotomized.

At the time of closure, the vastus lateralis muscle falls over the lateral aspect of the shaft of the femur. Separateabsorbable sutures are used to approximate the edges of the fascia of the vastus lateralis and the fascia lata. If atransverse incision has been made in the fascia lata, the cut edges should be approximated.

BIBLIOGRAPHY

BOST F.C., SCHOTTSTAEDT E.R., LARSEN L.J. - Surgical approach to the hip joint. In: American Academy ofOrthopedic Surgeons: Instructional Course Lectures. vol. I I, p. 131. J. W. Edwards, AnnArbor, 1954.

1.

BRACKETT E.R. - A study of the different approaches to the hip pins with special reference to the operationsfor curved trochanteric osteotomy and for arthrodesis. Boston Med. Surg. J.. 166, 235. 1912.

2.

CAPENER N. - The approach to the hip joint (Editorial). J. Bone Joint Surg.. 32B. 147, 1950.3.CARNESALE P.G. - Extensile exposure of the acetabulum. In: EDMONSON A. S.. CRENSHAW A. H.Campbell’s operative orthopaedics. C.V. Mosby Co.. St. Louis, 6th ed., p. 75. 1980.

4.

CUBBINS W.R., CALLAHAN J.J., SCUDERI C.S. - Fractures of the neck of the femur. Surg. Gynecol. Obstet., 5.


23 of 24 11/19/03 1:11 PM

68, 87, 1939.EDMONSON A.S.. CRENSHAW A.H. - Campbell’s operative orthopaedics. 6th ed. C.V. Mosby Co.. St. Louis,1980.

6.

FAHEY J.V. - Surgical approaches to bones and joints. Surg. Clin. North Am., 29, 65, 1949.7.GIBSON A. - Posterior exposure of the hip joint. J. Bone Joint Surg., 32B. 183, 1950.8.GIBSON A. - The posterior lateral approaches to the hip joint. In: American Academy of Orthopedic Surgeons: instructional Course Lectures, Vol. 10, p. 175. J.W. Edwards, Ann Arbor, 1953.

9.

HARDINGE K. - The direct lateral approches to the hip. J. Bone Joint Surg., 64B, 17. 1982.10.HARRIS W.H. - A new lateral approach to the hip joint. J. Bone Joint Surg., 49A, 891, 1967.11.HARRIS W.H. - Extensive exposure of the hip joint. Clin. Orthop.. 91, 58, 1973.12.HENRY A.K. - Extensile exposure, 3rd ed. Churchill Livingstone, Edinburgh, 1972.13.HOPPENFELD S., DEB0ER P. - Surgical exposures. The anatomic approach. J.B. Lippincott, Philadelphia, 1984.

14.

HORWITZ T. - The posterolateral approach in the surgical management of basilar neck, intertrochantericand subtrochanteric fractures of the femur. Surg. Gynecol. Obstet., 95, 45, 1952.

15.

HOVELIUS L., HUSSENIUS A., THORLING J. - Posterior versus lateral approach for hip arthroplasty. Acta Orthop. Scand., 48, 47, 1977.

16.

IYER K.M. - A new posterior approach to the hip joint. Injury, 13, 76, 1981.17.JERGENSEN F., ABBOTT L.C. - Comprehensive exposure of the hip joint. J. Bone Joint Surg., 37A, 798, 1955.

18.

JOYCE J.J., HARTY M. - The anatomical base of the hip joint exposure. Clin. Orthop.. 98, 27, 1974.19.JUDET R., JUDET J., LETOURNEL E. - Fractures of the acetabulum: classification and surgical approaches foropen reduction. J. Bone Joint Surg., 46A, 1615, 1964.

20.

KNIGHT R.A., SMITH H. - Central fractures of the acetabulum. J. Bone Joint Surg., 40A, 1, 1958.21.KOCHER T. - Textbook of operative surgery. Adams arid Charles Black, London, 1903.22.LOWELL J.D., AUFRANC O.E. - The anterior approach to the hip joint. Clin. Orthop.. 61, 193, 1968.23.LUCK J.V. - An approach for hip construction: broad visualization without osteotomy of the greatertrochanter. Clin. Orthop., 91, 70, 1973.

24.

LUDLOFF K. - The open reduction of the congenital hip dislocation by an anterior incision. Am. J. Orthop. Surg., 10. 438, 1912.

25.

MARCY G., FLETCHER R.S. - Modification of the posterolateral approach to the hip for insertion of femoralhead prostheses. J. Bone Joint Surg., 36A, 142, 1954.

26.

MCFARLAND B., OSBORNE G. - Approach to the hip, a suggested improvement on Kocher’s method. J. Bone Joint Surg.. 36B, 364, 1954.

27.

MOORE A.T. - The self-locking metal hip prosthesis. J. Bone Joint Surg., 39A, 811, 1957.28.OBER F.R. - Posterior arthrotomy of the hip joint. J.A.M.A., 83, 1500, 1924.29.OSBORNE R.P. - The approach to the hip joint. Br. J. Surg., 18, 4, 1930.30.ROOT L., SIEGAL T. - Osteotomy of the hip in children. Posterior approach. J. Bone Joint Surg., 62A, 571,1980.

31.

SMITH-PETERSEN M.N. - A new supra-articular subperiosteal approach to the hip joint. Am. J. Orthop., Surg., 15, 592, 1917.

32.

SMITH-PETERSEN M.N. - Approach to the exposure of the hip joint for mold arthroplasty. J. Bone Joint Surg.. 31A, 40, 1949.

33.

SUTHERLAND R., ROWE M.J. Jr. - Simplified surgical approach to the hip. Arch. Surg., 4, 144, 1944.34.URIST M.R. - Fracture dislocation of the hip joint. J. Bone Joint Surg., 30A, 3, 1948.35.WATSON-JONES R. - Fracture of the neck of the femur. Br. J. Surg., 23, 787. 193536.


24 of 24 11/19/03 1:11 PM

Documents

Surgery Exposure Hip - Arthrosurface · Surgery Exposure Hip ... interval between the gluteus maximus and medius; ... a limited extent sufficient to identify specific structures and